Concussion Evaluation with SCAT2

The article below points out the short coming of concussion management in the NHL and the lack of validity of sideline measures like the SCAT2. It is my opinion that the SCAT2 is more appropriately used as a means of identifying progression of recognized concussion and not necessarily as a means of identifying concussion. The importance of recognizing the progression of a traumatic brain injury, that is the deterioration of function suggesting more serious injury, and need for emergency transport is obvious. I concur with the author and the latest research that the SCAT2 should not be used to identify concussion on its own and certainly should not be used to return a player to the game in the face of other signs and symptoms of concussion. Moreover, the sensitivity of any test is diminished without a prior baseline test as a comparison point. I recommend comprehensive baselines that include at the very least a functional neurological exam, posturography, VNG for visual motor function and neurocognitive testing with ImPACT test. Additionally, it is my opinion that making a return to play decision solely based off of symptom reporting is a serious mistake. Objective functional assessments over symptom tracking is the approach at Brain Centers NW. Dr. David Burns

NHL Looking For Solutions on its Own Concussion Protocols

I was searching the other day through the NHL rule book and came across the proper protocol for players to go through when they have been told they have received a concussion. They must go throught the SCAT2 evaluation process before proceeding back into any type of play.

As I was checking all this out I came across another article written by Jeff Klein in regards to Colorado’s Gabriel Landeskog, who was ‘clocked’ in a game recently in San Jose. After going through all the proper procedures, the NHL started to realize something that maybe they needed to have done a while back.

Let’s take a look at what they have found out!

NHL GRAPPLES WITH APPLYING ITS OWN CONCUSSION PROTOCOLS

Colorado’s Gabriel Landeskog, the youngest captain in N.H.L. history and last season’s Calder Trophy winner as the league’s top rookie, did not play last week. But what happened to him in the aftermath of a heavy body check he received raised concerns that the league’s concussion protocols may be out of step with current scientific research.

On Jan. 26 in San Jose, Landeskog was on the wrong end of a crushing first-period hit from Sharks defenseman Brad Stuart, whose shoulder cracked into Landeskog’s head.

The hit was deemed legal by the referees, a call that passed review by Brendan Shanahan and the N.H.L.’s hockey operations department. Although Rule 48 on head checking was strengthened two seasons ago to penalize players who target an opponent’s head, if contact is made in the course of delivering a full body check, the hit is legal.

Additionally, the rule permits hits in which “the opponent put himself in a vulnerable position immediately before or simultaneously with the hit or the head contact.”

Landeskog, 20, said the hit was hard but clean. “I was kind of reaching for the puck and didn’t brace myself enough,” he said.

Another aspect of the episode, however, was troubling. Immediately afterward, Landeskog skated off and needed assistance to get to the dressing room. He remained out of the game and was examined by a doctor, in accordance with N.H.L. protocols on head injuries, until late in the second period. He passed the examination and returned to play part of that period and all of the third.

But in Edmonton last Monday, two days after the hit, Landeskog did not play. The team said he was out with head and leg injuries. He continued to travel with the team to Vancouver and Calgary, but he remained out of the lineup.

The Avalanche followed N.H.L. protocol in allowing Landeskog to return after he passed the SCAT2 evaluation exam, the standard for on-the-spot concussion assessment. But the latest research suggests that players suspected of having a concussion should be kept out of games no matter how they do on the SCAT2.

The team has not announced that Landeskog sustained a concussion but did place him on the injured reserve list Friday with a head injury. There is no timetable for his return. It is well known, however, that concussion victims sometimes do not show symptoms until days after an incident.

“When it comes to evaluating concussions, SCAT2 or any of those sideline screening tests really have no reliability,” said Dr. Paul S. Echlin, a concussion specialist and researcher in Burlington, Ontario, who has done two recent studies of concussions in hockey. “If you see it happen and you see the reaction, then you don’t let the player go back in. That’s the worst thing you can do, expose him to a second or third hit that can be really dangerous.”

The most well-known example was Sidney Crosby’s concussion sustained at the Winter Classic on Jan. 1, 2011, when he was clipped by Washington’s David Steckel near the end of the second period. Crosby played the third period, then started the next game on Jan. 5 at Tampa Bay. But a relatively routine shove into the boards from behind by Victor Hedman triggered symptoms that kept Crosby out of the Penguins lineup for 10 months.

That March, the N.H.L. revised its concussion protocol, mandating a player’s removal from the game if he reports symptoms or shows signs of loss of consciousness, impaired motor coordination, balance problems, or slowness to get up; or if he has a blank or vacant look, is disoriented, clutches his head after a hit or has a visible facial injury in combination with any of the above.

According to the protocol, the player is to be examined by the team doctor, not the trainer, in a quiet place free from distraction, using “an acute evaluation tool” like the SCAT2, as opposed to a quick rinkside assessment.

Still, on Nov. 26, 2011, Crosby’s teammate Kris Letang was rocked by a hit from Montreal’s Max Pacioretty that broke his nose. He left the game, reportedly passed the concussion protocol and came back to score the winning goal. But symptoms emerged later, and Letang was out for almost two months.

The N.H.L. has made strides on concussions in many areas, but cases like Letang’s and Landeskog’s suggest that even the league’s current protocol for concussion assessment may be too lenient, allowing players to return to the ice too soon after a jarring hit to the head.

Last November in Zurich, scientists and sports administrators gathered for the Fourth International Consensus Conference on Concussion in Sport to review the latest research. According to Ken Dryden, the Hall of Fame goalie and former member of Canada’s Parliament who attended the event, “the Zurich conference agreed to a clear, certain message: ‘When in doubt, sit them out.’”

That is not yet the standard in the N.H.L., where teams and the players are ever eager to shake off injuries, even from blows to the head, and get back in the game.